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°t�ulN' • SAN JOAQUIN COUNTY • _ __ ENVIRONMENTAL HEALTH DEPARTMENT LOP ` SITE MITIGATION 600 East Main Street, Stockton, CA 95202-3029 _ U IIT IV Telephone: (209) 468-3454 Fax: (209) 468-3433 Web:www.sigov.org/ehd 7YIy , WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION,,, NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. 4ENgcrvhN COU Pwp Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in com{illA�fcBrt�' T Site Location 142 S Industrial Avenue Cross Street E Fourth Street City Ripon Zip 95366 APN 259-39-010 Property contact Binayak Acharya g2Owner _ Nestle USA. Inc. Address 800 North Brand Blvd City Glendale Zip o912�03 Phone 661-255-1693 j{mI CS7 ContractorL� �c. Address Y e City�_ Lic ZPhone eowon`»em`I Ccs[ 3525 Hyland Avenue.Suite 200 ConsultanVSub Cntr Mar ego,neol ms. Address y� City Costa Mesa Lie 778024 Phone 714-662-2759 Billable Party Envlronn,emW cost Management.mc. Address 3525 Hyland Avenue,Suite 200 City Costa Mesa Zip 92626 Phone 714-662-2759 GIS Coordinates.X 6381507.6274 Y 2092131.8211 CONSTRUCTION WORK TO BE PERFORMED: 0 NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER.OTHER) ®SOIL BORING IDs CPT-39(plus an unnamed boring next to the CPT hole for discrete groundwater sampling).Boring location based on ❑WELL IDs RWOCB Approval of June 11 2010 M-10A Investigation Work Plan ❑OTHERIDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 2 ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: ❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS __. __._ _.. TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER _ ❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL t0 Surface TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE K]PIPE _._..E SOIL BORING EJ PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) .,[]INJECTION(,.e.Air Sean. 0.,,,, ❑HAND AUGER GROUT SPECIFICATIONS 5% bentonite and cement mix _❑OTHER: ❑OTHER: APPROX.BORING DEPTH _ <100 feet b_gss_ ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia'_ COMMENTS:Property owned by Nestle. CPT-39 location field selected based on utilities and road access See attached map NOTE: OFFSfTE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs: ❑ PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑ EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:❑ COMMENTS AUGERS []HOSE E]PIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE CO 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulations,and all applicable California laws. Signed P;'D .,.- Title/Company Project Manager, Environmental Cost Management Print Name Binayak Acharya Date August 27.2010 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS �ZF219 Nr�tf5T�2i A L (illIty , ?�//A/ WORK PLAN DATED-sj 4,et GNiaD/D. /Ck/Lt CAJ Apr*,( 0 Z1/,0 APPLICATION ACCEPTED BY DAe AREA GROUT INSPECTION BY _ FINAL INSPECTION BYdaoo a �� — DATE DESTRUCTION INSPECTION BY DATE COMMENTS/CON D ITI ONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# Z 1✓� $ 122x ' �Z SR# ORDGS RO# 35PIR ��,p 2so0 yr , C-57 WC WAIVER __ C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT 65 ENCROACHMENT DOC EHD 29-01 07/28/10 WELL PERMIT APP